| NPI | 1003643248 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: CT 12.015147) |
| Additional Taxonomies | 163WP0808X Registered Nurse, Psych/Mental Health (Licence: CT 179444) |
| Enumeration Date | 2024-09-19 |
| Last Update Date | 2025-07-30 |